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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057000034
Report Date: 10/01/2021
Date Signed: 10/01/2021 04:05:44 PM

Document Has Been Signed on 10/01/2021 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ARC OF AMADOR AND CALAVERAS, THEFACILITY NUMBER:
057000034
ADMINISTRATOR:KARYN GREGORIUSFACILITY TYPE:
775
ADDRESS:153 BELLVIEWTELEPHONE:
(209) 754-4001
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY: 40CENSUS: 0DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ericka Beltran, Program DirectorTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) T. White arrived unannounced on this day for the purpose of conducting a Required 1 year inspection. LPA arrived at 10:15 AM and met with Program Director (PD) Ericka Beltran. Present at the facility on this day was 0 clients and 4 staff along with the PD.

At 10:30 AM, LPA toured the facility with PD Beltran and inspected food services. Clients provide their own lunches but facility does have a plan in place for meals if needed. LPA observed facility does not manage medications. LPA inspected changing area, which was clean and odor free. Bathroom was inspected. Hand washing areas were clean and in good repair. Hot water was measured in client shared bathrooms at 122 and 121.8 degrees F. Temperature measured at 71 degrees Fahrenheit. PD stated facility reopened 09/13/2021. Fire extinguisher was last inspected on 06/10/2021. LPA observed mitigation plan completed. Facility has a 30 day supply of Person Protective Equipment (PPE) available. LPA observed smoke detector and carbon monoxide in operating condition during inspection. Fire drill was last conducted on 08/18/2021.

LPA observed staff on zoom calls with clients. There were no clients present at the facility during inspection.

- Hot water temperature in the clients shared bathroom measured at 122 and 121.8 degrees F.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with PD. A copy of report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2021 04:05 PM - It Cannot Be Edited


Created By: Treana White On 10/01/2021 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ARC OF AMADOR AND CALAVERAS, THE
FACILITY NUMBER: 057000034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 82088 (e)(1). LPA observed clients shared bathroom measured above 120 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2021
Plan of Correction
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Program Director (PD) adjusted hot water temperature in the clients shared bathroom. PD will submit proof hot water temperature is between 105 and 120 degrees F.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2021


LIC809 (FAS) - (06/04)
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